Daly Charles A, Cho Brian H, Desale Sameer, Aliu Oluseyi, Mete Mihriye, Giladi Aviram M
Curtis National Hand Center, Baltimore.
MedStar Health Research Institute, Hyattsville, MD.
J Hand Surg Am. 2019 Sep;44(9):720-727. doi: 10.1016/j.jhsa.2019.05.020. Epub 2019 Jul 13.
Underinsured hand trauma patients are more likely to be transferred to quaternary care centers, which burdens these patients and centers. By increasing insurance coverage, care for less severe upper-extremity injuries may be available closer to patients' homes. We evaluated whether the 2014 expansion of Medicaid in Maryland under the Affordable Care Act decreased the number of uninsured upper-extremity trauma patients and the volume of unnecessary emergency trauma visits at our hand center.
We identified all upper-extremity trauma patients between 2010 and 2017 at our hand trauma referral center. Injury severity was classified based on the need for subspecialty care. Bivariate relations between insurance status and demographic covariates, including injury type and distance, both before and after Medicaid expansion were evaluated. We used patient-level and multinomial logistic regression models to evaluate changes in payer and transfer appropriateness.
We studied 12,009 acute upper-extremity trauma patients. With Medicaid expansion, the percentage of trauma patients with Medicaid coverage increased from 15% to 24%, with a decrease in uninsured from 31% to 24%. After Medicaid expansion, non-transfer patient appropriateness decreased and appropriateness of transfers remained consistent across all payers. The average distance patients traveled for care remained similar before and after expansion.
Medicaid expansion significantly decreased the proportion of uninsured upper-extremity trauma patients. We identified no significant changes in the distances these patients traveled for specialized care. In addition, the appropriateness of transferred patients did not change significantly after expansion, whereas appropriateness of nontransferred patients actually declined after Medicaid expansion.
This study indicates no notable change in adherence to transfer guidelines after expansion, and a possible increase in use of emergency services by newly insured patients.
保险不足的手部创伤患者更有可能被转至四级医疗中心，这给这些患者和中心带来了负担。通过增加保险覆盖范围，对于不太严重的上肢损伤的治疗可能在更靠近患者家的地方就能获得。我们评估了2014年马里兰州根据《平价医疗法案》扩大医疗补助计划是否减少了上肢创伤未参保患者的数量以及我们手部中心不必要的急诊创伤就诊量。
我们确定了2010年至2017年间在我们手部创伤转诊中心的所有上肢创伤患者。根据专科护理需求对损伤严重程度进行分类。评估了医疗补助计划扩大前后保险状况与人口统计学协变量（包括损伤类型和距离）之间的双变量关系。我们使用患者层面的多项逻辑回归模型来评估付款人变化和转诊适宜性。
我们研究了12009例急性上肢创伤患者。随着医疗补助计划的扩大，有医疗补助覆盖的创伤患者百分比从15%增至24%，未参保患者从31%降至24%。医疗补助计划扩大后，非转诊患者的适宜性降低，所有付款人的转诊适宜性保持一致。患者就医的平均距离在扩大前后保持相似。
医疗补助计划的扩大显著降低了上肢创伤未参保患者的比例。我们发现这些患者接受专科护理的就诊距离没有显著变化。此外，扩大后转诊患者的适宜性没有显著变化，而未转诊患者的适宜性在医疗补助计划扩大后实际上有所下降。
本研究表明扩大后在遵循转诊指南方面没有显著变化，新参保患者使用急诊服务的情况可能有所增加。
